Case Presentation

Acute Care Nursing / Practical

Pulmonary Edema

Prepared by
Ibrahim Ayasreh

Supervised by
Dr. Musa Al-Hassan

2009
Pulmonary Edema
Pathogenesis of pulmonary Edema
Ventilation Perfusion Match
 Signs & symptoms
• Acute Dyspnea , Orthopnea
• Paroxysmal nocturnal dyspnea
• Crackles ,Rales, Ronchi
 Wheezing
 Cough, Pink frothy sputum
 Tachycardia, tachypnea
 Prolonged expiration phase
 Accessory muscle use
 Lung crepitations
 Investigations for pulmonary Edema
 Chest X-rays :
Cardiomegally, Pulmonary edema, infections , pleural effusion, …etc)

 ECG :
Brady or tachy arrhythmias, Atrial fibrillation, ischemia, previous or
silent myocardial infarction, L.V. hypertrophy

 ABGs :
hypoxia, respiratory acidosis.

 Echocardiogram :
Ejection fraction, LV size.

 CBC:
Hb, RBCs, WBCs, PT, PTT
 Treatment

• Oxygen therapy.
• Diuretics: remove excess fluids from the
body.
• Digoxin: increase myocardial contractility.
• Dopamine : if hypotension occur.
• Aspirin: for all patients of CADs.
• CPAP: if severe congestion occur.
 Patient Profile
 Patient's name: Salem Mahmoud
 Age: 66 yr
 occupation : Retired
 Hospital: KAUH.
 Ward: CCU.
 Admission date: 9 / 5 / 2009.
 Medical diagnosis: Pulmonary edema.
 Diet: low sugar, low salt diet.
 Physical limitation: bed rest.
 Allergies: no history of allergy to food or drugs.
 Chief Compliant & Present History
• Pt said: “ Yesterday at 8 O'clock, I came to hospital because I had

severe shortness of breathing and fatigue “

• last night, during watching TV patient experienced severe dyspnea and shortness
of breathing and cough associated with frothy pink sputum, in addition to severe
fatigue that patient couldn’t move alone even for small steps.

• He was admitted to emergency room of KAUH , the physician ordered Oxygen

administration through O2 mask, and ECG was done but there is no significant
changes except Q wave on leads V2-V4 indicating that patient had old anterior
MI, and cardiac enzymes were within normal, Blood pressure was slightly
elevated 140 /95 mmHg, heart rate was 112 beats/minute, other vital signs were
normal. X-rays was ordered and the result indicates that there is pulmonary
edema in both lungs , physician ordered Lasix (Furosemide) to remove excess
fluids from the body. The physician decided to admit the patient to CCU for
further monitoring and treatment.
 Past History & Family History

• Past History:
1) Hypertension : since 26 years.
2) Diabetes Mellitus : since 20 years
3) Old anterior myocardial Infarction : before 12 years (1997).

• Family History:
- His father is died with age of 75 years, as a result of heart attack.
- His mother is died, as a result of heart attack.
- His older brother is died with heart attack and was complaining of DM.

Strong Family history

 Functional Assessment
@ Activity/ Exercise:
- He said that he doesn't do any type of regular exercise.
- He said that he had severe fatigue , so simple daily activities
such as feeding, dressing, toileting need assistance.

@ Sleep:
- He said that he usually wake up during night because of
shortness of breathing.
- He can’t sleep except in sitting position , because he feel
heaviness on chest during supine position.
 Functional Assessment
@ Nutrition:
- The patient likes to eat sweet, and he like to drink gaseous drinks.
- He usually drinks tea, but with low sugar, he drinks about 12

glasses of tea daily. He also doesn't like drinking coffee.

- He avoid eating high-fat food .

@ Smoking and substance use:

- The patient said that he smokes about 1 packet (20 cigarettes) /day.
- He said that he smokes since about 45 years.
- The patient doesn't take any drugs except prescribed medication for
Hypertension ( Norvasc, Capoten) and diabetes (Glucophage,
Glibenclamide) , in addition to aspirin.
 Physical Examination

@ General survey:

- Patient appeared anxious and pale in general.

- Patient is alert and oriented.
- No recent weight changes .
- Weight : 55 Kg. Height: 158 cm.
- BMI now is about 22.03 ------------- Normal.
- Facial expressions are symmetric and appropriate with his
anxious mood and affect (furrow eyebrows and absence of
smile).
- Patient at most times is in sitting position, because it is better
for breathing.
 Physical Examination
@ Respiratory System:

- Respiratory rate is 28 breathes/ minute ( tachypnea).

- Lateral diameter (72 cm) is approximately 2: 1 Anterioposterior diameter (38 cm).
- There is periodical coughs with pink frothy sputum.
- Symmetrical but shallow chest expansion during breathing.
- Patient use muscles other than normal such as abdominal muscles and
strneomastoid muscle
- Tactile Fremitus: Increased in Fremitus
- Percussion over lungs:
There is evident dullness over the inferior parts of the lungs and scattered over the
superior parts , indicating abnormal accumulation of fluids in lung tissues.
- Abnormal sounds of crackles are obvious and clear during auscultation over lungs,
they are intermittent . They are heard at both inspiration and expiration.
- There is decreased breath sounds during auscultation related to bronchial
constriction.
 Cardiovascular system
• Estimation of jugular venous pressure:
was about 2 cm above sternal angle on the vertical ruler.
Interpretation: JVP = (2 + 5) = 7 mmHg -------- within normal.
• Apical impulse is palpable at fifth intercostals space with midclavicular line.
* Rate: 110 beats/ minute (tachycardia). * Rhythm: regular.
* Strength: weak. * Duration: very short.
• Percussion of heart:
Dullness between 2nd and 6th intercostals space at left ( Cardiomegally).
• Inspection and palpation of arms:
* Hands and arms are pale in color, with slightly cyanosed nailbeds.
* Capillary refill: previously discussed (within 4 seconds the nailbeds return
pink).
* Radial Pulse: 110 beats/minute, regular, weak (+1 on scale), symmetric bilaterally.
* Blood pressure: 130 / 75 mmHg.
* Allen's test: the color returned within 7 seconds after releasing pressure over radial.
• Inspection and palpation of legs:
* Legs are pale in color, Femoral pulse: 109 beats/minute (regular, weak, symmetric).
* Popliteal pulses: very weak, symmetric bilaterally.
* Posterior tibialis and dorsalis pedis are not palpable.
 Subjective Data
• Patient said: “ I can't move outside my bed, I feel fatigued rapidly
after even two steps".

• Patient said: " I have a difficulty in breathing, I can't breath well

except if I in setting position”

• Patient said:" During sleep at night , I wakes up many times because I feel
may breathing stop, but I feel better when I go outside and
breathe fresh air".

• Patient said:" Sometimes I can’t do anything by my self such as bathing

or dressing , I need assistance to do these activities".

• Patient said:" I feel anxious , because of inability to breathe sometimes, and

the side effects of medications such as polyuria.”
 Laboratory Findings
CBC

result Normal range

RBCs 5.1x 106 / mm3 WNL

WBCs 6.3 x 103 mm3 WNL

Platelets 200 x 103 / mm3 WNL

Hgb 16.4 g/dL WNL

Hct 49 % WNL

PTT 27 seconds WNL

PT 17 seconds Increased (warfarin)

 Laboratory Findings
ABGs
Test Results Note

PH 7.32 Decreased - Acidosis

PCO2 49 mmHg increased

PO2 85 mmHg WNL

O2 saturation 91 % Slightly decreased

HCO3 25 mEq/L WNL

 Laboratory Findings
Blood Chemistry
Na+ 139 mEq/L WNL

K+ 3.9 mEq/L WNL

Ca+ 2.3 mmol/L WNL

Creatinine 63 µmol/L WNL

BUN 13 mg/dL WNL

Cholesterol 255 mg/dL At upper border line

HDL 40 mg/dL Must be > 40

For this patient
LDL 170 mg/dL Slightly elevated

Glucose 135 mg/dL elevated

 Laboratory Findings
Cardiac Enzymes

Test Result

CPK Negative

Troponine Negative
 Diagnostic Procedures

• ECG:
- There sinus tachyarrhythmia ( P : 110 b/m).
- There is abnormal Q wave at leads V2 – V4 this indicates old
anterior MI.

• Echocardiogram:
- Ejection Fraction: 40 %
- Anterior wall hypokinesia.
- other results are normal .
 Diagnostic Procedures

• Chest X-rays:
- There is obvious white patches at lower parts of lungs indicating
pulmonary edema.
- There is white patchy area along the bronchi.
- There is obvious Cardiomegally.
X-rays patient with PE
 Medications
Name classification Dose Frequency
& Route
Digoxin Cardiac 40 mg 1X1
glycosides P.O
Furosemid Loop diuretics 5 mg 1/2 X 1
P.O
Atenolol Bet-blockers 100 mg 1/2 X 1
Anti-hypertensive P.O
Lipitor HMG-CoA 20 mg 1X1
reductase P.O
inhibitors
Zantac H2-blockers 150 mg 1 X1
Antacid. P.O
 Nursing Diagnosis
• Ineffective Airway clearance related to Increased bronchial secretions and
bronchial constriction As manifested by cough and sputum production (pink,
frothy), dyspnea, and X-rays show white patchy area along the bronchi.

• Impaired Gas Exchange Related to accumulation of fluids in the alveoli and

impaired ventilation perfusion ratio As manifested by ABGs results (PCO2:
49 mmHg, PH: 7.32, PO2: 85mHg, SPO2: 91%), and tachypnea, Dyspnea,
and fatigue, cyanosis of fingers.

• Decreased cardiac output Related to inability to meet metabolic demand

AMB, dyspnea, & delay capillary refill (4 seconds), positive Allen's test.
 Nursing Diagnosis

• Activity intolerance Related to Decrease cardiac output and alteration of

oxygen transportation As manifested by inability to walk two steps without
being fatigued, severe dyspnea with exertion, and patient verbalizations .

• Anxiety related to breathlessness and medication’s side effects As

manifested by patient verbalization and facial expressions.
 Planning

• Goals:

- To improve airway clearance and potency.

- To maintain optimal gas exchange.
- To improve cardiac output.
- To improve patient’s activity tolerance.
- To relieve anxiety.
 Planning
• Expected outcomes ( Ineffective airway Clearance):
* Patient will be able to show decrease cough
and sputum production.
* Patient will be able to report less dyspnea
and effective deep breathing.
* Patient will be able to show increased breath sounds during
auscultation.

• Expected outcomes ( Impaired Gas Exchange):

* Patient will be able to show ABGs within acceptable limits.
* Patient will be able to show absence of cyanosis at fingers.
 Planning
• Expected outcomes ( Decreased Cardiac Output):
* Patient will be able to show return of pink color of nailbeds
within 2 seconds during capillary refill test.
* Patient will be able to show negative Allen's test.

• Expected outcomes ( Activity Intolerance):

* Patient will be able to show a measurable increase in
tolerance to activity with absence of dyspnea and excessive
fatigue.
* Patient's skin will remain warm and dry during activity.
 Planning

• Expected outcomes ( Anxiety):

* Patient will be able to verbalize decrease in feeling of anxiety .

* Patient will be able to show more comfortable about side effects
of medication.
 Implementation
Ineffective airway clearance

• Assist the patient in performing coughing and deep breathing

exercises to enhance patient’s breathing and cheat expansion and
to remove excess secretions from tracheobrochial tree to improve
airways potency.

• Put patient is semi –Fowler position to enhance chest expansion

and improve gas exchange.

• Perform chest physiotherapy if needed to this patient which includes

10 -15 minutes two or three time per day of postural drainage and
chest percussion to mobilize secretions in smaller airways that can’t
be removed by coughing or suctioning.

• CPAP
CPAP
 Implementation
Impaired Gas Exchange

• Maintain oxygen administration device as ordered, attempting to

maintain oxygen saturation at 90% or greater. This provides for
adequate oxygenation.

• Position patient in high-Fowler’s position to facilitate

ventilation/perfusion matching.

• Assess arterial blood gases regularly to assess the level of oxygen and
carbon dioxide , and to assess the effectiveness of therapeutic
interventions.

• Give diuretics as doctor order to remove excess water from the alveoli.

• Assess skin color for development of cyanosis, as result of hypoxia

 Implementation
Decreased Cardiac Output

• Give Digoxin and other inotropic medication as doctor order.

• Maintain optimal fluid balance.

• Maintain physical and emotional rest :

1) Restrict activity. This reduces oxygen demands.

2) Provide quiet, relaxed environment. Emotional stress increases
cardiac demands.
3) Organize nursing and medical care. This allows rest periods.
 Implementation
Activity intolerance
• Assess the levels of oxygen in the blood (by evaluating ABGs), because decreased blood supply
is one of the most causes of fatigue and activity intolerance.
• Encourage the patient to do energy conservative techniques such as:
a) Sitting to do tasks Standing requires more work.
b) Pushing rather than pulling exercises is encouraged.
c) Sliding rather than lifting exercise.
d) Resting for at least 1 hour after meals before starting a new activity.

• Assist with Activities of daily living (ADLs) as indicated; however, avoid doing for patient what he
or she can do for self. Assisting the patient with ADLs allows for conservation of energy. Caregivers
need to balance providing assistance with facilitating progressive endurance that will ultimately
enhance the patient's activity tolerance and self-esteem.
• Progress activity gradually, as with the following:
a) Active range-of-motion (ROM) exercises in bed, progressing to sitting

and standing
b) Dangling 10 to 15 minutes three times daily.
c) Deep breathing exercises three times daily.
d) Sitting up in chair 30 minutes three times daily
e) Walking in room 1 to 2 minutes three times daily
f) Walking in hall 25 feet or walking around the house, then slowly
progressing, saving energy for return trip
 Implementation
Anxiety
• Psychological support.

• Provide quiet good-ventilated environment for patient

to decrease stress.

• Develop a trusting & caring relationship with the

patient is critical in reducing anxiety.

• Spiritual role.
 Evaluation
• 1) Goal was met: (for ineffective airway clearance)
- Patient show decrease in amount of sputum and less frequent coughs.
- Patient reports less dyspnea and no wheezing when auscultation.
- Normal breath sounds are heard better than before application of

nursing interventions.

• 2) Goal was met: (for impaired gas exchange)

- Last testing of ABGs results were within normal limits (PO2: 90
mmHg, PCO2: 41 mmHg, PH: 7.41, O2 saturation: 94 %).
- Cyanosis disappeared in the tips of fingers.
- Patient became more energetic rather than previous status before

intervening, and this indicate good oxygenation.

Evaluation
• 3) Goal was not met: (for decreased cardiac output)
- capillary refill: the pink color return within4 seconds.
- Allen’s test still positive ( 7 seconds).

4) Goal was partially met: (for activity intolerance)

- The patient now is able only to move inside his bed, such as taking a

glass of water, responds to telethon at bedside.

- The patient still have fatigue or dyspnea for some activities such as

dressing, walking inside his room, and he need assistance to do these

activities.
Evaluation
5) Goal was met: (for Anxiety)
- patient show more comfort to the environment and
therapeutic regimen.
- facial expression show smile with straight eyebrows
(comfort)